The great names in aviation belong to pilots who did things first. Orville Wright: First to fly. Charles Lindberg: First to fly solo across the Atlantic. Chuck Yeager: First to fly faster than the sound of his own engine.
Now add to that list Pietro Marsala, a man who’s done all three at once. He’s made a noise greater than a sonic boom, navigated a gulf wider than the Atlantic, and is literally the first man (of his kind) to fly in a big way.
Marsala’s aviation first?
He’s the first person with type 1 diabetes (T1D) to be granted a First Class Medical certification by the Federal Aviation Administration (FAA), allowing him to make his living as the pilot of an airliner. While this is a big step for Marsala, it’s a giant leap for all PWDs (people with diabetes): the official breaking down of one of the last remaining barriers to their career options. No more will children with diabetes who have dreams of working in the clouds be told to dream of something else.
Now, truly, the sky is no longer the limit for people with diabetes.
Other major nations such as Canada and the United Kingdom updated their rules in 2012 to allow pilots with insulin-treated diabetes to pilot commercial planes as long as they’re accompanied by a qualified second crew member. But the in history of the U.S., this has never been allowed.
That is, until October 2019, when the FAA announced it would start allowing a “subset of low-risk” applicants to be considered for commercial airline pilot status.
Since that initial news announcement, lots of questions arose about just what the process entailed. Through Marsala, we’ve learned a lot about what it’s going to take as a person with diabetes to become a commercial airline pilot. The requirements are quite stringent, to be sure:
- Your A1C results for a year need to be sent to the FAA.
- You also need to be using a continuous glucose monitor (CGM) and must submit a full six months of recorded glucose data, along with time-in-range information.
- You need to prove that you are under the care of an endocrinologist, and must also visit an ophthalmologist and a cardiologist to get an ECG (electrocardiogram) heart health test.
- If you’re 40 or older, a physical stress test is also required.
Regarding glucose levels, the FAA hasn’t published specific averages or A1C values required, but rather appears to be looking at the broader picture of “management” (which patients will appreciate!).
Once flying, an accompanying Excel spreadsheet links all of the above data to flight time. Any T1D pilot hoping to renew their license will need to resubmit an updated spreadsheet every six months. This is an approach pioneered by Marsala.
In short, there’s a lot of paperwork required — which, if actually done on paper, would probably be enough to build a complete Air Force of paper airplanes.
Marsala, who hails from Scottsdale, Arizona, says he was one of those children who dreamed of flight from the beginning. His earlier memories include a desire to become a commercial pilot, and he loved doing flight simulators as a kid and teenager. As soon as he was old enough, Marsala started his flight training in Phoenix, a city whose fair weather attracts a ton of flight training. Marsala worked hard and became a licensed pilot, earning his private pilot’s license.
Pilot licenses are formally called certificates and they come in a variety of flavors. He could be a student pilot without any passengers or cargo, could get a limited certification for sport or recreational flying, and could become a private pilot of small aircraft. He had mounted the first hurdle — getting his private pilot certification — and had started preparing for his path toward commercial airline piloting, when diabetes came to call in January 2012.
At 21 years old, Marsala was misdiagnosed initially as a type 2 diabetes (T2D) with a very high A1C and was placed on insulin. The FAA promptly pulled his medical certification.
“It was a really bad day for me,” Marsala said, recalling that time in his life.
But he had worse days ahead.
Assuming he was a T2D, but in reality, being a young adult T1D in a protracted honeymoon phase, Marsala dieted, ate very low-carb, and was able to get off insulin. After six months, he re-obtained his medical certification.
He finished his commercial ticket and his flight instructor certification before noticing a trend of rising blood sugars each morning.
But 11 months after being initially diagnosed as a T2D, Marsala went to another endocrinologist and received a correct diagnosis of T1D. Of course, his medical certification was once again revoked and that, Marsala says now, “was the hardest day of my life.”
But like the mythical Phoenix itself, Marsala yet again rose from the ashes. He obtained a private pilot-level “special issuance” medical that allowed him to work as a flight instructor on insulin. Per the existing FAA rules, Marsala could work as a flight instructor since the agency views instructors as teachers who happen to be pilots rather than pilots who happen to teach. This is no small distinction, as it means that PWDs could earn a living teaching others to fly without requiring one of the higher-level medical certificates to make a paycheck in the sky.
And that’s how Marsala racked up so much time aloft on insulin.
It wasn’t the career he had imagined, but at least he was flying and supporting himself. And while he was happy to be able to fly, the rules struck him as unfair.
With his limited medical certification, he could legally teach, and he could fly a planeload of people, so long as his passengers weren’t paying him. But there was a “different safety standard once people are paying.” It had nothing to do with the size of the plane, it was just whether or not the passengers took out their wallets. It seemed random, strange, and unfair to Marsala.
And that led him to first connecting with the FAA, to make a difference in the world of aviation for PWDs in the U.S.
On a vacation to Washington, D.C., in June 2016, Marsala and his girlfriend at the time found themselves standing in front of the FAA building. She basically double-dog dared him to go in and make his case that insulin shouldn’t limit him. He bowed under pressure but didn’t make it past the security guard.
Still, the encounter resulted in an opening of communication between the insulin-shooting flight instructor and the powers-that-be in the medical section of the FAA. That’s when he connected with Dr. James DeVoll, manager of medical appeals at FAA — someone who became a close contact with Marsala and was instrumental in moving this through to the end result of an FAA policy change.
Marsala started sharing his CGM data, along with spreadsheets he created that lined up his flying hours with his glucose reports. This allowed the FAA doctors to actually understand what his blood sugar was doing in flight, from takeoff to touchdown. Eventually, this Excel spreadsheet data linked to flight-time would become part of the FAA-adopted rules used to obtain a commercial pilot license or the renewal.
“I wasn’t scared to share my data with the FAA,” he says. He would go on to keep sharing data on a regular basis for the following three years.
During this time, he logged more than 4,500 flight hours on insulin — three times the minimum hours needed to fly for an airline. We may never know officially how much Marsala’s data played a part, but there’s no doubt he’s had a significant role in changing the D-world.
“It is a hard process to go through,” Marsala says, “They are picky on who they are selecting.”
Even so, he’s quick to praise the FAA, saying that it was a “great experience,” and he felt that the FAA was working with him to make it happen, rather than working against him. Marsala says he has stable, good A1Cs and spends a very high percentage of time in range, but he’s keeping the exact number private. Likewise, if there are hard numbers that have to be achieved, the FAA isn’t saying what they are either.
Marsala, for one, prefers it that way. He hopes the FAA is taking a broader, holistic view of diabetes control. “I’m not perfect,” he says, “but I do a fairly good job.”
While Marsala has been a pathfinder for PWDs. He bombarded the FAA with a blizzard of data that no doubt had a hand to play in the FAA coming around to seeing that insulin-using pilots deserve the chance to prove that they are safe.
But keep in mind that his path is unique, so his journey may not inform exactly what others will experience. Consider the fact that the FAA had granted (and then revoked) his medical twice before. He was already in the system; they had data on him from before, during, and after his diagnosis.
Marsala rocks a Dexcom G6 CGM when he’s flying, and uses MDI (multiple daily injections) with long-acting Tresiba basal insulin and fast-acting Apidra insulin. He says he eats around 100 carbs per day and is an advocate of the Juice Box Podcast’s approach of “being bold with insulin.”
He uses two sets of blood glucose (BG) targets:
- The 80-100 mg/dL range when not flying.
- A higher 100-150 mg/dL range when in flight. “But if I’m flying, 80 is that much closer to 60… 60 is that much closer to 50… (that is) much closer to 40, so I don’t take these risks.”
In his flight bag, Marsala carries glucose tabs and he typically snacks on cashews, cheese sticks, and mixed nut bars to keep his BGs steady with the high fiber and high protein they contain. The young pilot says he’s never gone low in flight, and his best numbers have actually been in flight because he’s “very focused and determined” to keep them in target range.
When women first gained access to the cockpit, some passengers actually deplaned when they learned a woman was flying the plane. The same thing happened to early pilots of color. Marsala hopes that won’t be an issue and won’t come into play, but he recognizes it might be a factor that comes up from passengers.
Unlike skin color or gender, no one would know that his insulin comes from a pen, not a pancreas, unless he keyed the intercom and announced it to the cabin along with the flight time, altitude, and temperature at the destination. That assumes, of course, that an airline would hire him in the first place.
Aside from what’s legal, Marsala is quick to point out that he hopes diabetes would never come into play one way or another. But rather than view it as a liability, he views his medical status as an advantage. A forward-thinking airline might like the publicity and good public relations that being on the cutting edge can bring with the public, he points out. This might be an airline that already has people of color, women, and women of color at the controls (along with LGBT, etc.) — an airline that doesn’t cater to the kind of people who deplane if they find out the captain isn’t a white man.
To his surprise, the now 29-year-old Marsala learned that his first-of-its-kind medical certification was only good for six months from the time he applied for it in November 2019, rather than mid-April 2020 when he actually received it. This was a shock given that normal first class medical certificates for those 40 or younger who are not on insulin last for a full year.
For Marsala, that meant his newly-obtained commercial piloting status was only good for a hair over six weeks. And it happened to come at a time when the world’s airline industry has been largely shutdown without regular commercial flight travel, due to the global COVID-19 pandemic.
After an initial freak out, and after checking in with the FAA, he learned that while he needed his medical examination annually, the practical effect is that he’d be required to supply fresh CGM and flight data to the FAA every six months to maintain his status. He views this as all part of the cost of being a pioneer, and hopes it will be easier in the future.
Marsala says he’s proud to have overcome the biggest obstacle of all time. He knows now that it will all work out, and he’s still young enough to have a great airline career.
“It’s such an ironic time, it’s been a wild ride,” he said.
Marsala’s future plans? Long-term, he’d like to fly for American Airlines, as they have a strong track record when it comes to hiring minorities.
Not to belittle the achievements of any of the great aviators of the past, but many times being first was largely a matter of luck. Even the two Wright brothers flipped a coin to choose which of them would pilot the Flyer on that famous day in December of 1903. But if ever there was a pilot who deserved to be first — who earned it — it is Marsala. His efforts gathering data, and his willingness to take a risk and share it with the authorities month after month after month, year after year, is a large part of why this change happened.
Although, he does point out that the long, twisted path for him was, “Not blue skies and tailwinds all the way.”
Of course, Marsala didn’t set out to join the famous firsts. He just wanted to achieve his childhood dreams of flying an airliner. An automatic “no” seemed fundamentally unfair to him.
“First or last, I wanted everybody to have a fair chance,” he says. But first, he was. Marsala’s achievement has felled one of the last remaining barriers for people with T1D.
And now, with paper in hand, he’s posed to be the first man of our kind to earn a living in the front of a commercial airliner. Wright, Lindberg, Yeager, Marsala. All first class, all the way.
You can find Pietro Marsala sharing his story, including images of his diabetes and piloting adventures, on Instagram at @marsala90.
Wil Dubois lives with type 1 diabetes and is the author of five books on the illness, including “Taming The Tiger” and “Beyond Fingersticks.” He spent many years helping treat patients at a rural medical center in New Mexico. An aviation enthusiast, Wil also works as a private flight instructor. He lives in Las Vegas, with his wife and son.